Global eradication of infectious disease: the rise and fall of a big idea
Anon . “Stamping out infectious disease: the rise and fall of a big idea”. Health Protection Matters, issue 10. Published by the UK Health Protection Agency, www.hpa.gov.uk.
Globalisation and its associated migrations, and other societal and climatic changes, are affecting priorities in public health protection both nationally and internationally. As a result, the total elimination of many currently prevalent infectious diseases may not be possible, or indeed desirable, in the same way that typhoid, tuberculosis and diphtheria were eradicated in the past, at least in western societies. Whereas at the end of the 20th century it seemed to the World Health Organisation that global eradication of both poliomyelitis and measles was feasible, these goals now appear less straightforward. Many countries have the infrastructure to stamp these infections out, and have done so, but the threat of their re-introduction is far greater as the world population is now so mobile, and resource-poor countries lack the necessary infrastructure to contain them. Funding is often inadequate or insufficiently sustained for constant delivery of the necessary vaccinations, case recognition is delayed and contact-tracing facilities are often poor. In democratic societies the level of enforcement needed to “stamp out” human infectious diseases may no longer be palatable. In the global context, there are many factors that may impede the eradication of an infectious disease including climatic instability, unfavourable cost/benefit ratios and political and cultural obstacles to immunisation programmes. When few national borders are impervious to humans and compulsory universal immunisation is neither acceptable nor achievable, the goal of eradication may have passed its usefulness. Trying to achieve the unattainable – total elimination – is doomed to failure and may compromise the achievement of the attainable – effective disease suppression and control.
Local and international influenza pandemic contingency plans
Chamberland M . “Trying to stop an influenza pandemic before it starts”. Hinton A and Conlon C . “Pandemic flu planning in Oxfordshire: a primary care trust perspective”. Health Protection Matters, issue 10. Published by the UK Health Protection Agency, www.hpa.gov.uk.
These articles describe two initiatives, one global and the other local, to respond to the expected impending influenza pandemic, either caused by a mutated form of avian influenza A (H5N1) or by a different flu virus. The first article discusses a novel “rapid containment” initiative by the World Health Organisation (WHO), which relies on sensitive surveillance systems in areas where a flu pandemic might originate. The rapid containment strategy aims to stop the spread of the infection at its source. WHO released a revised version of its rapid containment protocol in October 2007. The basic containment strategy is geographically based, with antiviral medications and non‑pharmaceutical measures being made available in a containment zone surrounding the initial cluster of cases. The containment zone is the largest possible area that can be created and maintained. Around the containment zone is a buffer zone. The focus in the containment zone is to prevent the further spread of disease by providing medication from the WHO stockpile of 30 million doses of the antiviral drug oseltamivir. The first shipments can be delivered to the international airport nearest the containment zone within 24 hours, but countries need to plan how they will distribute and monitor the delivery of the drugs to households in the containment zone. Movement restrictions will be applied into and out of the containment zone to prevent any spread into the buffer zone. The WHO protocol proposes that the containment interventions should remain in place for between four and five weeks, but with surveillance continuing for several months. The article recognises that preventing a pandemic at its source in this way has never been attempted before, and the strategy could be compromised if there was a simultaneous explosion of cases globally or if early recognition failed. The second article describes the contingency plans of the Oxfordshire primary care trust (PCT) in dealing with the impacts of a pandemic locally.
UK NHS staff health survey
Anon (2008). “The health of the health service’s staff in the UK” [editorial]. The Lancet 371(9621), 1309. Published by Elsevier Limited, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, tel: 1865 843 077, fax: 1865 843 970, web: www.thelancet.com.
For the past few years, NHS staff have been asked about their work, attitudes and experiences. The results of the 2007 survey by the Healthcare Commission were recently released, with a high proportion of staff saying that their trust did not put care of patients or service users as a top priority. Many staff said they felt ignored by management. Nearly half reported working overtime without pay and 8% of respondents said they had experienced some form of discrimination. Moreover, 13% of respondents reported physical violence from patients or relatives, while the figures for ambulance staff and those in mental health trusts were higher. Additionally, 26% of staff reported harassment, bullying and abuse by patients or relatives, and 2% from another staff member. The survey asked about work-related stress and one-third reported such stress. If annual staff surveys have a practical purpose, improvements in staff health and how the NHS deals with staff who are ill will be two markers to look out for in the future. The NHS does provide health-related advice to staff, but future surveys by the commission need to ask more overt questions about the health of the health service’s staff.
Outbreak of Q fever in Scotland
Browning L and Couper S . “A rare case of Q fever”. Health Protection Matters, issue 10. Published by the UK Health Protection Agency, www.hpa.gov.uk.
This article reports the investigation and management of an outbreak of Q fever at a meat processing plant in central Scotland in 2006. Over half of the 250-strong factory workforce were affected. Q fever is a rare disease in the UK. It is caused by the bacterium Coxiella burnetii and is transmitted mainly by cattle, sheep and goats, with up to 20% of the UK’s sheep population thought to be infected. The main mode of transmission is through inhalation of aerosols or dust contaminated with C. burnetii person-to-person transmission is extremely rare. The infective dose is low and so large outbreaks can be caused by a small dose. The majority of those infected (around 60%) show no symptoms. Symptomatic patients may present with a variety of complaints, ranging from flu-like symptoms to pneumonia. Around 10% of those infected may develop chronic complications such as endocarditis. Public health officials were alerted to a potential problem at the factory when two of the employees were hospitalised with pneumonia. Other workers at the plant were complaining of flu-like symptoms. Initial tests for legionella proved negative. Within a week three further workers were hospitalised. An outbreak control team comprising representatives from the NHS, Health Protection Scotland, Health and Safety Executive, Food Standards Agency, local authority, Scottish Veterinary Service and Regional Virus Laboratory was assembled and a diagnostic protocol developed to test a range of potential pathogens, including adenovirus, mycoplasma, chlamydia, leptospirosis and C. burnetii.
Hand hygiene on cruise ships
Skipp M . “Hand hygiene on cruise ships”. Health Protection Matters, issue 10. Published by the UK Health Protection Agency, www.hpa.gov.uk.
Hand-washing is a key hygiene measure in many occupations, particularly where there is the potential for rapid spread of communicable diseases. The issue is of particular relevance due to the resurgence of norovirus in Europe and North America. This article discusses the importance of hand hygiene on cruise ships. Typically, these carry between 1,800 and 3,000 passengers together with up to 1,200 crew. Good hand hygiene is considered a vital part of food safety management and communicable disease control on cruise ships. Most infectious intestinal diseases can be spread via the faecal-oral transmission route, with an estimated 25%-40% of all food-borne illnesses caused by poor personal hygiene. Studies have shown that thorough hand washing using antimicrobial agents, hand drying using paper towels and use of alcohol-based hand sanitisers effectively reduce the risk of contamination. Cruise ship design should take account of the number, positioning and types of hand-wash stations provided for crew and passengers, based on guidance from the US Center for Disease Control, the US Vessel Sanitation Program and the UK Industry guide to good hygiene practice: catering guide – ships published by the Chartered Institute of Environmental Health. The availability and convenience of hand-wash facilities is an important factor in encouraging their use. All crew should be trained to follow specific hand-washing procedures reinforced through posters, advice notices and routine training sessions. Crew should wash their hands on specific occasions, such as entering food rooms and after using the toilet, coughing, sneezing, blowing their nose, smoking, eating, drinking, and handling dirty equipment. Food handlers have additional responsibilities, including wearing a food-handling glove over any wound dressing.
Preventing legionnaires’ disease
Woolnough K . “Something in the water?” Health Protection Matters, issue 10. Published by the UK Health Protection Agency, www.hpa.gov.uk.
The author calls for a better understanding of the legionella infection process and, in particular, the use of simple prevention and maintenance procedures to reduce the risk of outbreaks of legionnaires’ disease. There were 540 cases of the disease in England and Wales last year, with a mortality rate of 8%. Meanwhile, laboratories are seeing more samples testing positive for legionella bacteria. The chain of causation in legionnaires’ disease comprises a source of Legionella pneumophilia, a reservoir for it to grow, a means of transmission, and a susceptible host. This chain can be broken by effective prevention and control measures based on a legionella risk assessment of water systems. Laboratory testing is key to the successful appraisal of risk levels and the development of an effective control strategy, based on HSE’s Approved Code of Practice and Guidance for the Control of Legionella Bacteria in Water Systems (“L8”). The frequency of testing is determined by the risk assessment. Control measures should be verified by laboratory analysis of water samples rather than as a result of adequate maintenance regimes since even well-maintained systems are occasionally contaminated with legionella. Larger and older buildings represent a higher level of legionella risk. Hospitals, schools, care homes, prisons and apartment blocks are of particular concern. Good-quality sampling is essential for an accurate measure of infection, with samples being as representative as possible and undergoing as little change as possible before analysis.
Association between job control and the risk of stroke
Toivanen S (2008). “Job control and the risk of incident stroke in the working population in Sweden”. Scandinavian Journal of Work, Environment and Health published online first on 31 March 2008.
This study, of nearly three million working people, estimated the risk of incident stroke according to the level of job control and examined whether the association between job control and the risk of stroke varied as a function of gender. The age- and workhour-adjusted hazard ratio of the lowest versus the highest job-control quartile among the women was 1.25 for any stroke, 1.33 for intracerebral haemorrhage and 1.22 for brain infarction. The corresponding figures for the men were 1.24, 1.30 and 1.23, respectively. Adjustment for education, marital status and income attenuated these associations. The relative risk of stroke was higher in low job-control occupations and the association between job control and stroke subtypes varied as a function of gender. The relative risk of intracerebral haemorrhage was highest for the women in low job-control occupations.
Explaining gender differences in sickness absence
Laaksonen M, Martikainen P, Rahkonen O et al (2008). “Explanations for gender differences in sickness absence: evidence from middle-aged municipal employees from Finland”. Occupational and Environmental Medicine 65(5), 325-330. Published by BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR, tel: 020 7387 4499, fax: 020 7383 6661, web: oem.bmjjournals.com.
This study examined gender differences in sickness absence spells and sought to explain these differences. Some 5,470 female and 1,464 male employees of the City of Helsinki were surveyed at baseline in 2000-02. Women were found to have a 46% higher risk of self-certified sickness absence than men. Psychosocial working conditions and family-related factors did not affect the gender differences. The overall gender differences in sickness absence are due to relatively short absence spells being more common among women. In longer sickness absence spells the female excess is mainly explained by heavier burden of ill health and, to a lesser extent, by higher physical work demands among women. The authors found no support for greater vulnerability to health- and work-related problems among women as reasons for sickness absence.
Physical activity and cardiovascular health – the occupational paradox
Kukkonen-Harjula K . “Physical activity and cardiovascular health – work and leisure differ”(editorial). Scandinavian Journal of Work, Environment and Health 33(6), 401-404, web: www.sjweh.fi.
This editorial reviews several studies published in the issue addressing the associations between physical activity and cardiovascular disease (CVD). The first study, by Krause et al, highlights the relationship between occupational physical activity and atherosclerosis over an 11‑year period in a sample of 612 middle-aged Finnish men. The main finding was that high physical activity at work was positively associated with an accelerated progression of atherosclerosis after control for several CVD risk factors, including job factors related to work stress and leisure-time physical activity. Krause et al suggest that the relative aerobic strain of new workers, and those with new CVD diagnosis, should be assessed in jobs with high physical demands. The second study, by Virkkunen et al, investigated high physical workload, both on its own and in combination with two other exposures, noise and shift work. These authors studied how health effects were modulated through increased systolic blood pressure. The main finding was that high systolic blood pressure was associated with high workload, regardless of other exposures, leading to increased risk of coronary heart disease. The long-term follow-up cohorts of Krause et al and Virkkunen et al provide further evidence that high physical activity at work may have detrimental effects on cardiovascular health. This finding is contrary to strong epidemiologic and experimental evidence indicating that low physical activity is an independent risk factor for CVD, especially atherosclerosis, and a sedentary lifestyle is a risk factor for many diseases. However, most of this evidence is based on physical activity during leisure time not on physical activity at work. Thus the resulting physiological effects of high energetic demands at work on physical fitness and work capacity are not the same as those from leisure-time exercise.
Tackling depression in the workplace
Burton WN and Conti DJ (2008). “Depression in the workplace: the role of the corporate medical director”. Journal of Occupational & Environmental Medicine 50(4), 476-481. Official Journal of the American College of Occupational and Environmental Medicine, published by Lippincott Williams & Wilkins, 351 W. Camden St, Baltimore, MD 21201, tel: 410 528 4000, web: www.joem.org.
Depressive disorders are a major health issue in the US workplace. They are responsible for significant direct and indirect costs to the employer in terms of medical and pharmaceutical costs, time absent from work and decreased productivity while on the job (presenteeism). The corporate medical director (CMD) or occupational health physician must be equipped to respond to this health problem, just as they must be able to respond to the more “traditional” workplace issues such as communicable disease, occupational exposures and work-related ergonomic injuries. An integrated response by the CMD includes forming partnerships with relevant departments such as the employee assistance programme, human resources, corporate benefits, and others measuring the impact of the disease and providing leadership with regard to interventions in health plan design, disability management, workplace policy, and education aimed at increasing awareness and destigmatisation.
Anxiety and depressive disorders in midlife
Stansfeld SA, Clark C, Caldwell T et al (2008). “Psychosocial work characteristics and anxiety and depressive disorders in midlife: the effects of prior psychological distress”. Occupational and Environmental Medicine published online first on 3 April 2008. DOI:10.1136/oem.2007.036640.
The association of work stressors and adult psychiatric diagnoses may be biased by prior psychological distress influencing perception of work or selection into unfavourable work. This study examined the extent to which the association between work stressors and adult psychiatric diagnoses is explained by associations with earlier psychological distress and whether childhood and early adulthood psychological distress influence reported midlife work characteristics. A follow-up was conducted at 45 years of 8,243 participants in paid employment from the 1958 British Birth Cohort. Childhood and early adulthood psychological distress were found to predict work characteristics in mid-adulthood, but do not explain the associations of work characteristics with depressive episode and generalised anxiety disorder in midlife. Work stressors are an important source of preventable psychiatric diagnoses in midlife. Psychological distress may influence selection into less advantaged occupations with poorer working conditions that may increase the risk of future depressive and anxiety disorders.
Predicting depression and absence from work
Brenninkmeijer V, Houtman I and Blonk R (2008). “Depressed and absent from work: predicting prolonged depressive symptomatology among employees”. Occupational Medicine Advance Access published on 22 April 2008, DOI:10.1093/occmed/kqn043.
The World Health Organisation considers depression a major health problem and a leading cause of disability. The authors sought to identify factors that may help to reduce depressive symptoms in a sample of employees sick-listed due to mental health problems. A total of 555 employees commenced the study and 436 participated in the second interview. Individuals with low education and sole breadwinners showed a less favourable course of depressive symptoms. Work resumption (partial and full) and changing the employee’s tasks (action by employer) promoted a more favourable course of depressive symptoms. The findings point to the importance of work resumption and a change in work tasks in order to promote recovery. Using these insights, management of employees suffering from depressive complaints may be improved.